Fillable UTAH Advance Directive Planning for Important Health Care

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UTAH Advance Directive Planning for Important Health Care

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1
UTAH
Advance Directive
Planning for Important Health Care Decisions
CaringI
nfo
1731 King St., Suite 100,
Alexandria,
VA 22314
www.caringinfo.org
800/658-8898
CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO), is a
national consumer engagement initiative to improve care at the end of life.
It’s About How You LIVE
It’s
About
How You LIVE is a national community engagement campaign encouraging
individuals to make informed decisions about end-of-life care and services. The campaign
encourages people to:
Learn about options for end-of-life services and care
Implement plans to ensure wishes are honored
Voice decisions to family, friends and health care providers
Engage in personal or community efforts to improve end-of-life care
Note: The following is not a substitute for legal advice. While CaringInfo updates the
following information and form to keep them up-to-date, changes in the underlying law can
affect how the form will operate in the event you lose the ability to make decisions for
yourself. If you have any questions about how the form will help ensure your wishes are
carried out, or if your wishes do not seem to fit with the form, you may wish to talk to your
health care provider or an attorney with experience in drafting advance directives. If you
have other questions regarding these documents, we recommend contacting your
state attorney general's office.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised 2020.
Reproduction and distribution by an organization or organized group without the written permission of the
National Hospice and Palliative Care Organization is expressly forbidden.
2
Using these Materials
BEFORE YOU BEGIN
1. Check to be sure that you have the materials for each state in which you may receive
health care.
2. These materials include:
•
Instructions for preparing your advance directive, please read all the instructions.
•
Your state-specific advance directive forms, which are the pages with the gray
instruction bar on the left side.
ACTION STEPS
1. You may want to photocopy or print a second set of these forms before you start so you
will have a clean copy if you need to start over.
2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide
you through the process.
3. Talk with your family, friends, and physicians about your advance directive. Be sure the
person you appoint to make decisions on your behalf understands your wishes.
4. Once the form is completed and signed, photocopy the form and give it to the person you
have appointed to make decisions on your behalf, your family, friends, health care
providers, and/or faith leaders so that the form is available in the event of an emergency.
5. You may also want to save a copy of your form in an online personal health records
application, program, or service that allows you to share your medical documents with
your physicians, family, and others who you want to take an active role in your advance
care planning.
3
INTRODUCTION TO YOUR UTAH ADVANCE DIRECTIVE
This packet contains a legal document, a Utah Advance Health Care Directive, that
protects your right to refuse medical treatment you do not want, or to request treatment you
do want, in the event you lose the ability to make decisions yourself. You may complete Part
I, Part II, or both, depending on your advance-planning needs. You must complete Part IV.
Part I lets you name someone, your “agent,” to make decisions about your medical care—
including decisions about life-sustaining procedures—if you can no longer speak for yourself.
This part is especially useful because it appoints someone to speak for you any time you are
unable to make your own medical decisions, not only at the end of life.
Part II lets you state your wishes about health care in the event that you can no longer
make your own health care decisions and you are terminally ill.
Part III tells you how to revoke or change your Directive.
Part IV contains the signature and witnessing provisions so that your document will be
effective.
Your Utah
Advance Health
Care
Directive
goes into effect when your doctor, physician
assistant, or advance practice registered nurse ("APRN") determines you are no longer able
to make an informed decision about receiving or refusing health care.
This form does not expressly address mental illness. If you would like to make advance care
plans regarding mental illness, you should talk to your physician and an attorney about an
advance directive tailored to your needs.
Note:
This
document
will be
legally binding
only if the
person completing
it is an
individual
of
sound
mind who is 18 years or older.
4
Completing Your Utah Advance Health Care Directive
How do I make my Advance Health Care Directive legal?
Utah allows your Directive to be oral or written. In order to make your Directive legally binding,
it must be witnessed by a disinterested adult, which means your witness can have no interest
in your estate or benefit from your death. If you are physically unable to sign the Directive, you
may arrange for someone to sign it in your presence at your direction.
Your witness cannot be:
•
The person who signed the Directive on your behalf,
•
Related to you by blood or marriage,
•
Entitled to any portion of your estate,
•
The beneficiary of your life insurance policy, trust, qualified plan, a pay on death account
or transfer on death deed,
•
Entitled to benefit financially from your death,
•
Entitled to a right to or interest in your personal property upon your death,
•
Directly financially responsible for your medical care,
•
A health care provider who is providing care to you or an administrator at a health care
facility in which you are receiving care, or
•
Your appointed agent or alternate agent.
Whom should I appoint as my agent?
Your agent is the person you appoint to make decisions about your health care if you
become unable to make those decisions yourself. Your agent may be a family member or a
close friend whom you trust to make serious decisions. The person you name as your agent
should clearly understand your wishes and be willing to accept the responsibility of making
health care decisions for you.
You can appoint a second person as your alternate agent. The alternate will step in if the first
person you name as an agent is unable, unwilling, or unavailable to act for you.
An agent may not be a health care provider for you, or an owner, operator, or employee of a
health care facility at which you are receiving care unless the agent is related to you by blood,
marriage, or adoption.
Can I add personal instructions to my Advance Health Care Directive?
One of the strongest reasons for naming an agent is to have someone who can respond
flexibly as your health care situation changes and deal with situations that you did not
foresee. If you add instructions to this document it may help your agent carry out your
wishes, but be careful that you do not unintentionally restrict your agent’s power to act in
your best interest. In any event, be sure to talk with your agent about your future medical
care and describe what you consider to be an acceptable “quality of life.”
5
Paragraph J in Part I allows you to decide whether your agent can override instructions you
give in Part II or be strictly bound by your directions.
What if I change my mind?
You may revoke your Advance Health Care Directive in the following ways:
•
Writing “void” across your Directive or obliterating it or asking another person to do the
same on your behalf.
•
Burning, tearing, or otherwise destroying or defacing your Directive in any manner
indicating an intent to revoke or asking another person to do the same on your behalf.
•
Signing and dating a written revocation of the Directive (or having a written revocation
signed and dated by an adult acting on your behalf and at your direction).
•
Orally expressing your intention to revoke the Directive in the presence of a witness
who would be qualified to witness your Directive, but cannot be the person who will
become your agent or default surrogate after the revocation.
•
Signing a new Directive.
A decree of annulment, divorce, dissolution of marriage, or legal separation revokes the
designation of your spouse as an agent, unless otherwise specified or you affirm your intent
to retain the spouse as your agent.
What other important facts should I know?
Directions to withhold or withdraw life sustaining care will not be honored during a patient’s
pregnancy.
If you object, your agent does not have the authority to admit you to a licensed health care
facility for long-term custodial placement other than for assessment, rehabilitative, or respite
care.
6
UTAH ADVANCE HEALTH CARE DIRECTIVE - PAGE 1 OF 7
My Personal Information
PRINT YOUR
NAME, ADDRESS,
TELEPHONE
NUMBERS, AND
BIRTH DATE
Name:
Street Address:
City, State, Zip Code:
Telephone: Cell Phone:
Birth Date:
PART I: Appointment of Agent (Health Care Power of Attorney)
This part allows you to name another person to make health care decisions
for you when you cannot make decisions or speak for yourself.
A. No Agent
If you do not want to name an agent: initial the box below, then go to Part
II; do not name an agent below. No on can force you to name an agent.
I do not want to choose an agent.
B. My agent
Agent’s Name:
_________________________________________________
Street Address:
City, State, Zip Code:
Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )
C. My Alternate Agent
PART I
INITIAL THIS
PARAGRAPH IF YOU
DO NOT WANT TO
NAME AN AGENT
PRINT THE NAME,
ADDRESS AND
TELEPHONE
NUMBERS OF YOUR
AGENT
PRINT THE NAME,
ADDRESS AND
TELEPHONE
NUMBERS OF YOUR
ALTERNATE AGENT
© 2005 National
Hospice and
Palliative Care
Organization
2020 Revised.
This person will serve as your agent if your agent, named above, is unable or
unwilling to serve.
Alternate Agent’s Name:
Street Address:
City, State, Zip Code:
Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )
7
UTAH ADVANCE HEALTH CARE DIRECTIVE - PAGE 2 OF 7
D. Agent’s Authority
GENERA
L
STATEMENT OF
AGENT'S
AUTHORITY
INITIAL THE
STATEMENT THAT
REFLECTS YOUR
WISHES
© 2005 National
Hospice and
Palliative Care
Organization
2020 Revised.
If I cannot make decisions or speak for myself (in other words, after my
physician, physician assistant, or advance practice registered nurse ("APRN")
finds that I lack health care decision making capacity under Section 75-2a-
104 of the Advance Health Care Directive Act), my agent has the power to
make any health care decision I could have made such as, but not limited to:
•
Consent to, refuse, or withdraw any health care. This may include care
to prolong my life such as food and fluids by tube, use of antibiotics,
CPR (cardiopulmonary resuscitation), and dialysis, and mental health
care, such as convulsive therapy and psychoactive medications. This
authority is subject to any limits in paragraph F of Part I or in Part II of
this Directive.
•
Hire and fire health care providers.
•
Ask questions and get answers from health care providers.
•
Consent to admission or transfer to a health care provider or health
care facility, including a mental health facility, subject to any limits in
paragraphs E and F of part I.
•
Get copies of my medical records.
•
Ask for consultations or second opinions.
My agent cannot force health care against my will, even if a physician has
found that I lack health care decision making capacity.
E. Other Authority
My agent has the powers below ONLY IF I initial the “yes” option that
precedes the statement. I authorize my agent to:
Yes No Get copies of my medical records at any time, even when
I can speak for myself.
Yes _____ No Admit me to a licensed health care facility, such as a
hospital, nursing home, assisted living, or other congregate facility for long-
term placement other than convalescent or recuperative care, unless I agree
to be admitted at that time.
8
UTAH ADVANCE HEALTH CARE DIRECTIVE - PAGE 3 OF 7
ADD INSTRUCTIONS
HERE ONLY IF YOU
WANT TO LIMIT OR
F. I wish to limit or expand the powers of my health care agent as
follows:
EXPAND
YOUR
AGENT'S
AUTHORITY
INITIAL WHETHER
YOU WANT TO
NOMINATE YOUR
AGENT AS YOUR
GUARDIAN IF YOU
NEED ONE
INITIAL WHETHER
YOU WANT YOUR
AGENT TO
CONSENT TO
MEDICAL RESEARCH
INITIAL WHETHER
YOU WANT YOUR
AGENT TO DONATE
YOUR ORGANS
INITIAL WHETHER
YOUR AGENT MAY
OVERRIDE YOUR
INSTRUCTIONS OR
STRICTLY ABIDE BY
THEM
© 2005 National
Hospice and
Palliative Care
Organization
2020 Revised.
G. Nomination of Guardian
Even though appointing an agent should help you avoid a guardianship, a
guardianship may still be necessary, Initial the “YES” option if you want the
court to appoint your agent or, if your agent is unable or unwilling to serve,
your alternative agent, to serve as your guardian, if a guardianship is ever
necessary.
YES NO
I being of sound mind and not under duress, fraud, or other undue influence,
do herby nominate my agent, or if my agent is unable or unwilling to serve, I
hereby nominate my alternate agent, to serve as my guardian in the event
that, after the date of this instrument, I become incapacitated.
H. Consent to Participate in Medical Research
YES NO I authorize my agent to consent to my
participation in medical research or clinical trials, even if I may not
benefit from the results.
I. Organ Donation
YES NO If I have not otherwise agreed to organ
donation, my agent may consent to the donation of my organs for the
purpose of organ transplantation.
J. Agent’s Authority to Override Expressed Wishes
Yes No My agent may make decisions about health
care that are different from the instructions in Part II of this form.
9
UTAH ADVANCE HEALTH CARE DIRECTIVE - PAGE 4 OF 7
PART II
PART II: My Health Care Wishes (Living Will)
I want my health care providers to follow the instructions I give them when
I am being treated, even if my instructions conflict with these or other
advance directives. My health care providers should always provide health
care to keep me as comfortable and functional as possible.
Choose only one of the following options, numbered Option 1
through Option 4, by placing your initials before the numbered
statement. Do not initial more than one option. If you do not wish
to document end-of-life wishes, initial Option 4. You may choose
to draw a line through the options that you are not choosing.
Option 1: I choose to let my agent decide. I have chosen
my agent carefully. I have talked with my agent about my health care
wishes. I trust my agent to make the health care decisions for me that I
would make under the circumstances.
Option 2: I choose to prolong life. Regardless of my
condition or prognosis, I want my health care team to try to prolong my life
as long as possible within the limits of generally accepted health care
standards.
Option 3: I choose not to receive care for the purpose
of prolonging life. Including food and fluids by tube, antibiotics, CPR, or
dialysis being used to prolong my life. I always want comfort care and
routine medical care that will keep me as comfortable and functional as
possible, even if that care may prolong life.
If you choose this option, you must also choose either (a) or (b), below.
(a) I put no limit on the ability of my health care provider or agent
INITIAL ONLY ONE
OF OPTIONS 1-4
IF YOU INITIAL
OPTION 3,
INITIAL YOUR
WISHES
REGARDING YOUR
HEALTH CARE
PROVIDER’S
ABILITY TO
WITHHOLD OR
WITHDRAW LIFE-
SUSTAINING CARE
© 2005 National
Hospice and
Palliative Care
Organization 2020
Revised.
to withhold or withdraw life-sustaining care.
(b) My health care provider should withhold or withdraw life-
sustaining care if at least one of the following initialed
conditions is met:
I have a progressive illness that will cause death
I am close to death and am unlikely to recover.
I cannot communicate and it is unlikely that my condition will
improve.
I do not recognize my friends or family and it is unlikely that my
condition will improve.
I am in a persistent vegetative state.
Option 4: I do NOT wish to express preferences about
end-of-life health care wishes in this Directive.
UTAH ADVANCE HEALTH CARE DIRECTIVE - PAGE 5 OF 7
Organ Donation (optional)
I do not want to be an organ donor.
I want to be an organ donor. In the event of my death I request
that my agent inform my family/next of kin of my desires to be an organ and
tissue donor if possible. My wishes are indicated below.
I wish to give:
any organs/tissues: or
only the following
organs/tissues:
Additional instructions about your health care wishes:
INITIAL ONLY ONE
ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE
PLANS
THESE
INSTRUCTIONS CAN
FURTHER ADDRESS
YOUR HEALTH CARE
PLANS, SUCH AS
YOUR
WISHES
REGARDING
HOSPICE
TREATMENT, BUT
CAN ALSO ADDRESS
OTHER
ADVANCE
PLANNING
ISSUES,
SUCH
AS YOUR
BURIAL WISHES
ATTACH
ADDITIONAL
PAGES
IF
NEEDED
© 2005 National
Hospice
and
Palliative Care
Organization
2020 Revised.
(attach additional pages if needed)
10
11
UTAH ADVANCE HEALTH CARE DIRECTIVE - PAGE 6 OF 7
PART III
REVOCATION
© 2005 National
Hospice and
Palliative Care
Organization
2020 Revised.
PART III: Revoking My Directive
I may revoke or change this Directive by:
1. Writing “void” across the form, or burning, tearing, or otherwise
destroying or defacing this document or directing another person to do
the same on my behalf;
2. Signing a written revocation of the Directive, or directing another person
to sign a written revocation on my behalf;
3. Stating that I wish to revoke the Directive in the presence of a witness
who is 18 years of age or older; will not be appointed as my agent in a
substitute directive; will not become a default surrogate if the Directive is
revoked; and signs and dates a written document confirming my
statement;
4. Signing a new directive. (If you sign more than one Advance Health Care
Directive, the most recent one applies.)
Note: If you do not want emergency medical services providers to provide
CPR or other life sustaining measures, you must work with a physician,
physician assistant, or advance practice registered nurse ("APRN") to
complete an order that reflects your wishes on a form approved by the Utah
Department of Health.
12
PART IV
PRINT YOUR NAME
DATE AND SIGN
AND PRINT
RESIDENCE
INFORMATION
R
ESTRICTIONS OR
LIMITATIONS
H
AVE YOUR
WITNESS SIGN AND
DATE AND PRINT
NAME HERE
© 2005 National
Hospice and
Palliative Care
Organization
2020 Revised.
UTAH ADVANCE HEALTH CARE DIRECTIVE - PAGE 7 OF 7
PART IV: Making my Directive Legal
I (your name),
sign this Directive voluntarily. I understand the choices I have made and
declare that I am emotionally and mentally competent to make this
Directive. My signature on this form revokes any living will or power of
attorney form, naming a health care agent, that I have completed in the
past.
Date:
Signature:
City, County, and State of Residence:
I have witnessed the signing of this Directive, I am 18 years of age or older,
and I am not:
1. Related to the declarant by blood or marriage;
2. Entitled to any portion of the declarant’s estate according to the laws of
intestate succession of any state or jurisdiction or under any will or
codicil of the declarant;
3. A beneficiary of a life insurance policy, trust, qualified plan, pay on death
account, or transfer on death deed that is held, owned, made, or
established by, or on behalf of, the declarant;
4. Entitled to benefit financially upon the death of the declareant;
5. Entitled to a right to, or interest in, real or personal property upon the
death of the declarant;
6. Directly financially responsible for the declarant’s medical care;
7. A health care provider who is providing care to the declarant or an
administrator at a health care facility in which the declarant is receiving
care; or
8. The appointed agent or alternate agent.
Signature of Witness: , Date, _
Witness printed name:
If the witness is signing to confirm an oral directive, describe below the
circumstances under which the directive was made.
C
ourtesy
of
Car
in
gIn
fo
1731 King St., Suite 100,
Alexandria,
VA
22314
www.caringinfo.org,
800-
658-
8898
13
You Have Filled Out Your Health Care Directive, Now What?
1. Your Utah
Advance Health
Care
Directive
is an important legal document. Keep the original
signed document in a secure but accessible place. Do not put the original document in a
safe deposit box or any other security box that would keep others from having access to it.
2. Give photocopies of the signed original to your agent and alternate agent, doctor(s), family,
close friends, clergy, and anyone else who might become involved in your health care. If you
enter a nursing home or hospital, have photocopies of your document placed in your medical
records.
3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your wishes
concerning medical treatment. Discuss your wishes with them often, particularly if your
medical condition changes.
4. You may also want to save a copy of your form in an online personal health records
application, program, or service that allows you to share your medical documents with your
physicians, family, and others who you want to take an active role in your advance care
planning.
5. If you want to make changes to your documents after they have been signed and witnessed,
you must complete a new document.
6. Remember, you can always revoke your Utah document.
7. Be aware that your Utah document will not be effective in the event of a medical emergency.
Ambulance and hospital emergency department personnel are required to provide
cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states
otherwise. These directives called “prehospital medical care directives” or “do not resuscitate
orders” are designed for people whose poor health gives them little chance of benefiting
from CPR. These directives instruct ambulance and hospital emergency personnel not to
attempt CPR if your heart or breathing should stop. In addition, Utah authorizes a special
type of order called a “Life with Dignity Order” that may be used in a similar manner. We
suggest you speak to your physician if you are interested in obtaining one of these orders.
CaringInfo does not distribute these forms.
OR donate online today: www.NationalHospiceFoundation.org/donate
Congratulations!
You’ve downloaded your free, state specific advance directive.
You are taking important steps to make sure your wishes are known. Please consider helping us
keep this resource free.
Your generous support to the National Hospice Foundation allows us to continue to provide FREE
resources, tools, and information to educate and empower individuals to access advance care
planning, caregiving, hospice and grief services.
Please show your support for our mission and consider making a tax-deductible gift
to the National Hospice Foundation today.
Since 1992, the National Hospice Foundation has been dedicated to creating FREE resources for
individuals and families facing a life-limiting illness, raising awareness for the need for hospice
and palliative care, and providing ongoing professional education and skills development to
hospice and palliative care professionals across the nation. To learn more, please visit
www.NationalHospiceFoundation.org
You may wonder if a gift of $35, $50 or $100 to the National Hospice Foundation would make a
difference, but it is only because of the generosity of others like you that these FREE resources
are made available.
Please consider supporting our mission by returning a generous tax-deductible donation.
Every gift makes a difference! Your gift strengthens the Foundation’s ability to provide FREE
caregiver and family resources.
Cut along the dotted line and use the coupon below to return a check contribution of
the most generous amount you can send. Thank you.
YES! I want to support the important work of the National Hospice Foundation.
$35
helps us provide webinars to hospice professionals
$50
helps us provide free advance directives
$100 helps us maintain our free InfoLine
$________ to support the mission of the National Hospice Foundation.
Return to:
National Hospice Foundation
PO Box 824401
Philadelphia, PA 19182-4401
2020AD
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